Knee joint surgical treatment

ABSTRACT

A surgical treatment of an ACL or a PCL of a knee joint under an arthroscope, includes: contacting a treating portion of an ultrasonic device with a start region to which the ACL or the PCL of a femur adheres, and excising the femur and a remaining ligament of the ACL, or the femur and a remaining ligament of the PCL by ultrasonically vibrating the treating portion, thereby exposing a footprint of the femur; and contacting the treating portion with an end region to which the ACL or the PCL of a tibia adheres, and excising the tibia and a remaining ligament of the ACL, or the tibia and a remaining ligament of the PCL by ultrasonically vibrating the treating portion, thereby exposing a footprint of the tibia.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a surgical treatment of a knee joint tobe performed under an arthroscope.

2. Description of the Related Art

It is known that, when performing an arthroscopic surgical treatment fora patient's knee joint, a surgeon proceeds with the treatment whileinserting and removing treatment devices through a portal many times inaccordance with a tissue of a treatment region with the progress of thetreatment, and the above treatment devices are, for example, a shaver toshave a soft tissue, an abrader burr to abrade a bone, or an RF deviceto excise the soft tissue while stopping bleeding.

BRIEF SUMMARY OF THE INVENTION

According to one aspect of the present invention, a surgical treatmentof an anterior cruciate ligament or a posterior cruciate ligament of aknee joint which is to be performed under an arthroscope, includes:inserting the arthroscope and a treating portion of an ultrasonic deviceinto a knee joint cavity; bringing the treating portion of theultrasonic device into contact with a start region to which the anteriorcruciate ligament or the posterior cruciate ligament of a femur adheres,and excising the femur and a remaining ligament of the anterior cruciateligament, or the femur and a remaining ligament of the posteriorcruciate ligament by ultrasonically vibrating the treating portion,thereby exposing a footprint region of the femur; and bringing thetreating portion of the ultrasonic device into contact with an endregion to which the anterior cruciate ligament or the posterior cruciateligament of a tibia adheres, and excising the tibia and a remainingligament of the anterior cruciate ligament, or the tibia and a remainingligament of the posterior cruciate ligament by ultrasonically vibratingthe treating portion, thereby exposing a footprint region of the tibia.

Advantages of the invention will be set forth in the description whichfollows, and in part will be obvious from the description, or may belearned by practice of the invention. The advantages of the inventionmay be realized and obtained by means of the instrumentalities andcombinations particularly pointed out hereinafter.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING

The accompanying drawings, which are incorporated in and constitute apart of the specification, illustrate embodiments of the invention, andtogether with the general description given above and the detaileddescription of the embodiments given below, serve to explain theprinciples of the invention.

FIG. 1 is a schematic view showing a treatment system for use in asurgical treatment of a knee joint;

FIG. 2 is a schematic view showing one example of an ultrasonictreatment device (an ultrasonic device) of the treatment system for usein the surgical treatment of the knee joint;

FIG. 3 is a schematic view showing a state where an arthroscope and atreating portion of the ultrasonic treatment device are inserted fromseparate portals, respectively, to an articular capsule of the kneejoint of a right knee seen from the anterior side;

FIG. 4 is a schematic side view showing a state where the knee joint ofthe right knee encapsulated in the articular capsule is seen from themedial side;

FIG. 5 is a schematic view showing a state where a medial meniscus, alateral meniscus, an anterior cruciate ligament and a posterior cruciateligament of the knee joint of the right knee are seen from the superiorside;

FIG. 6 is a schematic coronary cross-sectional view schematicallyshowing a state where there is inflammation of a synovial membrane inthe articular capsule of the knee joint;

FIG. 7 is a schematic view showing a state where an ultrasonic vibrationis transmitted to the treating portion of the ultrasonic treatmentdevice to excise the synovial membrane in the articular capsule of theknee joint under the arthroscope;

FIG. 8 is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to excise a damaged region of the meniscus of the kneejoint under the arthroscope;

FIG. 9A is a schematic view showing a state where a condition of acartilage of a joint excised with the treating portion of the ultrasonictreatment device to which the ultrasonic vibration is transmitted isenlarged and observed;

FIG. 9B is a schematic view showing a state where a condition of thecartilage of the joint abraded with an abrader burr is enlarged andobserved;

FIG. 9C is a schematic view showing a state where a condition of thecartilage of the joint excised with an RF device is enlarged andobserved;

FIG. 10A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to remove a treatment object region of the cartilage ofthe knee joint under the arthroscope;

FIG. 10B is a schematic view showing a condition where of a treatedsurface formed by the treating portion of the ultrasonic treatmentdevice when the ultrasonic vibration is transmitted to the treatingportion of the ultrasonic treatment device to remove the treatmentobject region of the cartilage of the knee joint under the arthroscope;

FIG. 11A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of a femurside of the knee joint under the arthroscope;

FIG. 11B is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of the femurside of the knee joint under the arthroscope, thereby exposing afootprint region (a region to which the anterior cruciate ligament isattached);

FIG. 11C is a schematic view showing a state where a concave hole (aconcave region) is formed from the footprint region toward a lateralsurface of a lateral condyle of the femur with the treating portion ofthe ultrasonic treatment device from which the ultrasonic vibration istransmitted to the footprint region of the anterior cruciate ligament ofthe femur side of the knee joint under the arthroscope;

FIG. 12A is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of a tibiaside of the knee joint under the arthroscope;

FIG. 12B is a schematic view showing a state where the ultrasonicvibration is transmitted to the treating portion of the ultrasonictreatment device to dissect the anterior cruciate ligament of the tibiaside of the knee joint under the arthroscope, thereby exposing thefootprint region (the region to which the anterior cruciate ligament isattached);

FIG. 12C is a schematic view showing a state where a concave hole (aconcave region) is formed from the footprint region toward a medial sideof a rough surface of the tibia with the treating portion of theultrasonic treatment device from which the ultrasonic vibration istransmitted to the footprint region of the anterior cruciate ligament ofthe tibia side of the knee joint under the arthroscope;

FIG. 13A is a schematic view showing a state where one end of aninstrument that guides a drill to form a tunnel in a tibia is disposedin the footprint region of the anterior cruciate ligament of the tibiaside of the knee joint or the concave hole formed in the footprintregion, and the drill can be guided from the other end present on anouter rough surface side of the tibia toward the one end;

FIG. 13B is a schematic view showing a state where one end of aninstrument that guides a drill to form a tunnel in a femur is disposedin the footprint region of the anterior cruciate ligament of the femurside of the knee joint or the concave hole formed in the footprintregion, and the drill can be guided from the other end thereof on anouter side of the femur toward the one end; and

FIG. 14 is a schematic view showing a state where a graft is interposedbetween a tunnel on the femur side and a tunnel on the tibia side to fixend portions of the graft to outer sides of the femur and the tibia,respectively.

DETAILED DESCRIPTION OF THE INVENTION

Embodiments of this invention will be described with reference to thedrawings.

When a knee joint 100 is treated, for example, a treatment system 10shown in FIG. 1 is used. The treatment system 10 has an arthroscopedevice 12, a treatment device 14, and a perfusion device 16.

The arthroscope device 12 includes an arthroscope 22 to observe an innerpart of the knee joint 100, i.e., the inside of a joint cavity 136 of apatient, an arthroscope controller 24 that performs image processing onthe basis of a subject image imaged by the arthroscope 22, and a monitor26 that displays the image generated by the image processing in thearthroscope controller 24. The arthroscope 22 is inserted into the jointcavity 136 of the knee joint 100 through a first cannula 18 a that formsa lateral portal 102 via which the inner part of the knee joint 100 ofthe patient communicates with an outer side of skin. It is to be notedthat a position of the portal 102 is not uniform but is suitablydetermined in accordance with a patient's condition.

The treatment device 14 has an ultrasonic treatment device 32, atreatment device controller 34, and a switch 36. Here, the treatmentdevice controller 34 supplies energy to the ultrasonic treatment device32 in accordance with an operation of the switch 36 to transmit anultrasonic vibration to a treating portion 68 of an after-mentionedprobe 66 of the ultrasonic treatment device 32. The treatment device 32is inserted into the joint cavity 136 of the knee joint 100 through asecond cannula 18 b that forms a medial portal 104 via which the innerpart of the joint 100 of the patient communicates with the outer side ofthe skin. It is to be noted that a position of the portal 104 is notuniform but is suitably determined in accordance with the patient'scondition. The switch 36 maintains, for example, a driven state of anultrasonic transducer in a state where the switch is pressed to beoperated, and when the pressed state is released, the driven state ofthe ultrasonic transducer is released.

Here, it is described that the one switch 36 is disposed, but theswitches may be disposed. An amplitude of the ultrasonic transducer cansuitably be set by the treatment device controller 34. In consequence,by the operation of the switch 36, a frequency of the ultrasonicvibration to be output from the after-mentioned ultrasonic transducer isthe same, but the amplitude may be different. Therefore, the switch 36can suitably switch the amplitude of the ultrasonic transducer to statessuch as two large and small states. For example, when the amplitude canbe switched to the two large and small states, the ultrasonic vibrationof the small amplitude is for use in treating comparatively soft tissuessuch as a synovial membrane 134, cartilages 112 a, 114 a and 118 a, andmeniscuses 142 and 144 shown in FIG. 3 to FIG. 5. The ultrasonicvibration of the large amplitude is for use in treating comparativelyhard tissues such as bones (a femur 112, a tibia 114 and a patella 118)shown in FIG. 3 and FIG. 4.

It is to be noted that, for example, the two switches 36 may be disposedin parallel, or a hand switch and a foot switch may selectively be used.Additionally, when the one switch 36 is switched to be used, theultrasonic vibration of the small amplitude may be output by oneoperation, and the ultrasonic vibration of the large amplitude may beoutput by two quick pressing operations as in a double click operationof a mouse for a computer.

The perfusion device 16 includes a bag-shaped liquid source 42 thatcontains a perfusion liquid such as physiological saline, a perfusionpump unit 44, a liquid supply tube 46 whose one end is connected to theliquid source 42, a liquid discharge tube 48, and a suction bottle 50connected to one end of the liquid discharge tube 48. The suction bottle50 is connected to a suction source attached to a wall of an operatingroom. In the perfusion pump unit 44, the perfusion liquid can besupplied from the liquid source 42 by a liquid supply pump 44 a.Additionally, in the perfusion pump unit 44, suction/suction stop of theperfusion liquid in the joint cavity 136 of the knee joint 100 to thesuction bottle 50 can be switched by opening/closing a pinching valve 44b as a liquid discharge valve.

The other end of the liquid supply tube 46 that is a liquid supply tubepath is connected to the first cannula 18 a. In consequence, theperfusion liquid can be supplied into the joint cavity 136 of the kneejoint 100 via the first cannula 18 a. The other end of the liquiddischarge tube 48 that is a liquid discharge tube path is connected tothe first cannula 18 a. In consequence, the perfusion liquid can bedischarged from the joint cavity 136 of the knee joint 100 via the firstcannula 18 a. It is to be noted that, needless to say, the other end ofthe liquid discharge tube 48 may be connected to the second cannula 18b, so that the perfusion liquid can be discharged from the knee joint100.

It is to be noted that, here, the perfusion liquid can be supplied anddischarged through the first cannula 18 a, but a function that iscapable of supplying and/or discharging the perfusion liquid may beimparted to, for example, the arthroscope 22. Similarly, the functionthat is capable of supplying and/or discharging the perfusion liquid maybe imparted to the ultrasonic treatment device 32. In addition, afunction that is capable of supplying and discharging the perfusionliquid through the second cannula 18 b may be imparted. Furthermore, theperfusion liquid may be supplied and discharged through separateportals.

As shown in FIG. 2, the ultrasonic treatment device 32 includes ahousing 62, a sheath 64 projected from the housing 62, and the probe 66inserted into the sheath 64. In particular, outer peripheral surfaces ofthe housing 62 and the sheath 64 have insulating properties. The probe66 is made of a metal material such as a titan alloy material capable oftransmitting the ultrasonic vibration. To a proximal end of the probe66, there is fixed an unshown ultrasonic transducer unit disposed in thehousing 62. In the ultrasonic treatment device 32, the treating portion68 of the probe 66 inserted into the sheath 64 is disposed together withthe sheath 64 in the joint cavity 136 through the second cannula 18 b.Further, when the switch 36 is pressed, energy is supplied from thetreatment device controller 34 to the ultrasonic transducer unit fixedto the proximal end of the probe 66, and the ultrasonic transducerultrasonically vibrates. This vibration is transmitted from the proximalend of the probe 66 toward a distal end side, and hence with the aid ofthe treating portion 68 of a distal end of the probe 66, the hard tissue(the bone tissue or the like) can be resected and the soft tissue (thecartilage, a membrane tissue or the like) can be excised.

It is to be noted that a shape of the treating portion 68 can suitablybe selected in accordance with a treatment region. Here, there isdescribed an example where a hook type of treating portion shown in FIG.2 is used, but various shapes such as a rake type, a blade type and acurette type can selectively be used in consideration of anaccessibility to the treatment region, an adaptability to the treatmenton the basis of a position, a shape, a size or the like of a bladeportion of the treating portion 68, or the like.

A structure of the knee joint 100 will briefly be described.Hereinafter, the knee joint 100 of a right knee will be described as anexample.

As shown in FIG. 3, the knee joint 100 is mainly constituted of a femur112, a tibia 114, a fibula 116, and a patella 118. As shown in FIG. 4,the knee joint 100 is encapsulated in a joint capsule 130. The jointcapsule 130 includes a fibrous tunica 132 on a lateral side and thesynovial membrane 134 on a medial side. The synovial membrane 134 formspleats and secretes a synovial fluid, and hence the knee joint 100smoothly moves. The inside of the joint capsule 130 is called the jointcavity 136. The joint cavity 136 is filled with the synovial fluid to besecreted from the synovial membrane 134. The joint cavity 136 of theknee joint 100 is incompletely divided into four cavities (asuprapatellar bursa, a patellofemoral joint cavity, a lateralfemorotibial joint cavity and a medial femorotibial joint cavity), andthe synovial membrane pleat is present as a partition wall between thesecavities.

Additionally, in the knee joint 100, each of the cartilages (jointcartilages) 112 a, 114 a and 118 a is present between the bones (thefemur 112, the tibia 114 and the patella 118). By the cartilages 112 a,114 a and 118 a, impact can be absorbed in the knee joint 100, and theknee joint 100 can smoothly move.

As shown in FIG. 3, surfaces of the femur 112 which are joined to thetibia 114 are referred to as a medial condyle 122 and a lateral condyle124, respectively. In a superior surface of the tibia 114, there are twosurfaces to be joined to the medial condyle 122 and the lateral condyle124 of the femur 112. Between the medial condyle 122 and the lateralcondyle 124 of the femur 112 and the upper surface of the tibia 114, themeniscuses 142 and 144 and ligaments 152 and 154 adhere.

As shown in FIG. 5, the meniscuses 142 and 144 form a pair on lateraland medial sides. A superior surface of the medial meniscus 142 extendsalong the spherical cartilage 112 a disposed in the medial condyle 122of the femur 112, and an inferior surface of the medial meniscus extendsalong the flat cartilage 114 a disposed on the superior surface of thetibia 114. Similarly, a superior surface of the lateral meniscus 144extends along the spherical cartilage 112 a disposed in the lateralcondyle 124 of the femur 112, and an inferior surface of the lateralmeniscus extends along the flat cartilage 114 a disposed on the superiorsurface of the tibia 114. Consequently, the meniscuses 142 and 144 areformed so that lateral edge portions of the meniscuses are thick andmedial edge portions of the meniscuses are thin. It is to be noted thatthe lateral edge portions of the medial meniscus 142 and the lateralmeniscus 144 are linked to the joint capsule 130.

In the knee joint 100, an anterior cruciate ligament 152 and a posteriorcruciate ligament 154 are present. When the knee joint 100 is seen froman anterior side, the anterior cruciate ligament 152 is present in theanterior side and the posterior cruciate ligament 154 is present in aposterior side. One end of the anterior cruciate ligament 152 is passedthrough a space between the medial condyle 122 and the lateral condyle124 of the femur 112 and fixed to the posterior side of the femur, andthe other end of the anterior cruciate ligament is fixed to the anteriorside of the superior surface of the tibia 114. The anterior cruciateligament 152 has its start region in a medial surface posterior regionof the lateral condyle 124 of the femur 112, and adheres to an anteriorintercondylar fossa area (an end region) of the tibia 114. One end ofthe posterior cruciate ligament 154 is fixed to a slightly anteriorregion of the femur 112, and the other end of the posterior cruciateligament is fixed to the posterior side of the superior surface of thetibia 114. The posterior cruciate ligament 154 has its start region in alateral surface anterior region of the medial condyle 122 of the femur112, and adheres to a posterior intercondylar fossa area (an end region)of the tibia 114.

Next, there will be described a method in which a surgeon (an operator)uses the treatment system 10 mentioned above to excise a damaged regionof the meniscus 142 or 144 under the arthroscope 22 to the patient whohas the damaged region in at least one of the meniscuses 142 and 144present between the femur 112 and the tibia 114 of the knee joint 100.

As to the damage of the meniscus 142 or 144 of the knee joint 100, ingeneral, there are a case where the meniscus is damaged due to anexternal injury or the like and a case where the meniscus is damaged dueto repeatedly loaded stress. As to the meniscus 142 or 144, the damagesare mainly and often caused to an anterior horn of the medial meniscus142 or posterior regions (posterior horns or posterior nodes) of themedial meniscus 142 and the lateral meniscus 144. In addition, when themeniscus 142 or 144 is damaged, as shown in FIG. 6, such inflammation asshown by a reference sign 134 a might be caused to the meniscus togetherwith the synovial membrane 134.

A condition of the knee joint 100 is confirmed by use of an X-ray, MRIor the like. When the damage is confirmed in the meniscus 142 or 144, adamaged condition of the meniscus 142 or 144 is confirmed in advance.

There are prepared an instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofexcising an inflamed region of the synovial membrane 134 and damagedregions of the meniscuses 142 and 144. It is to be noted that thetreating portion 68 of the ultrasonic treatment device 32 is formed intoa suitable shape such as the hook type.

The surgeon forms the first portal 102 on anterior and lateral side ofthe knee joint to the patient who bends the knee joint 100 of the rightknee. When necessary, the first cannula 18 a is disposed in the portal102. A distal end of the arthroscope 22 is disposed in the joint cavity136 of the knee joint 100 through the first cannula 18 a. Here, thefirst cannula 18 a is not necessarily required, when the perfusiondevice 16 is connectable to the arthroscope 22.

The joint cavity 136 of the knee joint 100 is filled with saline by useof the perfusion device 16. In this state, the medial side of the jointcavity 136 of the knee joint 100 is suitably observed by using thearthroscope 22. Further, the damaged region of the meniscus 142 or 144is disposed in a view field of the arthroscope 22 to confirm the damage.In addition, an inflamed condition of the synovial membrane 134 on themedial side of the joint capsule 130 of the knee joint 100 is confirmed.

The surgeon forms the second portal 104 on the anterior and medial sideto the patient who bends the knee joint 100. When necessary, the secondcannula 18 b is disposed in the portal 104. The treating portion 68 ofthe ultrasonic treatment device 32 is disposed in the joint cavity 136of the knee joint 100 through the second cannula 18 b. When the inflamedregion is present in the synovial membrane 134 of the joint capsule 130confirmed with the arthroscope 22, as shown in FIG. 7, the surgeonapproaches the inflamed region with the treating portion 68 of theultrasonic treatment device 32 to bring the treating portion intocontact with the inflamed region while observing the inflamed regionwith the arthroscope 22. Further, the surgeon operates the switch 36 ofthe treatment device 14 to generate the ultrasonic vibration of thesuitable amplitude in the ultrasonic transducer, thereby only moving thetreating portion 68 in an axial direction of the probe 66, whereby theinflamed region 134 a of the synovial membrane 134 and/or an inflamedsynovial membrane is excised with the treating portion 68 to which thevibration is transmitted. The excised inflamed region of the synovialmembrane 134 is flown with momentum in excising the region. At thistime, the surgeon suitably moves the ultrasonic treatment device 32 andalso suitably moves the arthroscope 22 to excise the inflamed region 134a of the synovial membrane 134 and/or the inflamed synovial membrane andfurther a peripheral region with the treating portion 68 of theultrasonic treatment device 32 while always disposing the treatingportion 68 in the view field of the arthroscope 22. In the synovialmembrane 134, the excised inflamed region 134 a and the peripheralregion are discharged to the suction bottle 50 through the first cannula18 a and the liquid discharge tube 48.

A head (a treating portion) of an unshown shaver that has heretoforebeen used in removing the inflamed region of the synovial membrane 134or the like has a structure to intertwine the inflamed region byperiaxial rotation. Thus, the shaver performs the treatment whileintertwining (winding) the inflamed region, and hence there is a highpossibility that a peripheral tissue in the knee joint 100 is woundduring the treatment. In addition, power is securely transmitted from amotor of the shaver to the head, and hence it is difficult to form aportion between the motor and the head of the shaver into a suitableshape, and additionally, a head portion is formed to be larger than thetreating portion 68 of the ultrasonic treatment device 32. Inconsequence, it is very difficult for the head portion of the shaver toespecially access the posterior side of the knee joint 100. Therefore,even by use of the shaver that has heretofore been used, it might bedifficult to remove the synovial membrane 134. When the treatment isperformed by using the ultrasonic treatment device 32, it is notnecessary to rotate the treating portion 68. Therefore, damages due tothe winding of the peripheral tissue in the knee joint 100 can bedecreased. In addition, when the treatment is performed by using theultrasonic treatment device 32, the treating portion 68 can be formedinto the suitable shape, the treating portion 68 can be formed to besmaller, and the probe 66 can be formed to be thinner, so that a movingrange of the treating portion 68 to the second cannula 18 b can beincreased. Therefore, in a case where the ultrasonic treatment device 32is used, for example, the posterior side of the knee joint 100 can moreeasily be accessed as compared with a case where the shaver is used.Consequently, in the case the ultrasonic treatment device 32 is used,the inflamed region of the synovial membrane 134 can more easily beexcised than in the case where the shaver is used.

In addition, as described above, the shaver has the structure tointertwine the inflamed regions of the synovial membrane 134 by theperiaxial rotation. Consequently, the shaver operates to tear off thesynovial membrane 134, and the excised region of the synovial membrane134 easily bleeds. On the other hand, the treating portion 68 of theultrasonic treatment device 32 does not periaxially rotate, and theinflamed region can be excised only by moving the treating portion inthe axial direction of the probe 66. Further, in the case where theultrasonic treatment device 32 is used, the excised region is flownunlike the case where the shaver is used, and hence the view field ofthe arthroscope 22, especially the view field of the treatment region iseasily acquired.

As described above, the surgeon removes the inflamed region of thesynovial membrane 134 by use of the ultrasonic treatment device 32, andthen while moving the arthroscope 22 to confirm the inside of the jointcavity 136 of the knee joint 100, the surgeon moves the ultrasonic′treatment device 32 to dispose the damaged region of the meniscus 142 or144 in the view field of the arthroscope 22 as shown in FIG. 8.Furthermore, the treating portion 68 of the ultrasonic treatment device32 is disposed to face the damaged region of the meniscus 142 or 144.That is, here, the treating portion 68 of the ultrasonic treatmentdevice 32 that is the same as the portion used to excise the synovialmembrane 134 is disposed as it is to face the damaged region of themeniscus 142 or 144. Therefore, the treating portion 68 approachestreatment regions such as the anterior horn of the medial meniscus 142and the posterior horns and posterior nodes of the medial meniscus 142and the lateral meniscus 144 to face them. The treating portion 68 ofthe ultrasonic treatment device 32 is brought into contact with thetreatment region of the meniscus 142 or 144, and the switch 36 isoperated to generate the ultrasonic vibration of the suitable amplitudein the ultrasonic transducer. In consequence, the treating portion 68 towhich the ultrasonic vibration is transmitted is only moved in the axialdirection of the probe 66, to remove the damaged meniscus 142 or 144 inthe treatment region. That is, a region of the meniscus 142 or 144 inwhich tear or damage denaturation occurs is excised with the treatingportion 68 to which the ultrasonic vibration is transmitted, to performdissection. As shown in FIG. 10B, the surgeon can easily form a surfacetreated by the treating portion 68 of the ultrasonic treatment device 32to which the ultrasonic vibration is transmitted, as a smooth surfacewithout forming any corner portions in the treatment region of themeniscus 142 or 144 by suitably moving the treating portion 68 inaccordance with the movement of the probe 66 in the axial direction.When the treatment object region of the meniscus 142 or 144 is removed,a dented region having a substantially circular vertical cross sectionis formed, and there are smoothly continued a removed surface from whichthe treatment object region of the meniscus 142 or 144 is removed and anon-removed surface adjacent to the removed surface. In consequence, theregion treated with the treating portion 68 of the ultrasonic treatmentdevice 32 by the surgeon is hard to be stuck on another region.

It is to be noted that, by the operation of the switch 36, the amplitudeof the ultrasonic transducer in a case where the synovial membrane 134is removed may be adjusted to be different from the amplitude of theultrasonic transducer in a case where the damaged region of the meniscus142 or 144 is excised.

It might be difficult for the unshown shaver head that has heretoforebeen used in shaving the bone to access the damaged region of themeniscus 142 or 144. The ultrasonic treatment device 32 can be formedinto a suitable shape between the proximal end of the probe 66 and thetreating portion 68 of the distal end, the treating portion 68 can beformed to be small, and hence the ultrasonic treatment device can moreeasily have access toward the posterior side of the knee joint 100 thanthe shaver. Consequently, in the case where the treatment is performedby using the ultrasonic treatment device 32, the damaged region of themeniscus 142 or 144 can more easily be excised than in the case wherethe shaver is used. Additionally, as shown in FIG. 9A, the surfacetreated by the ultrasonic treatment device 32 can smoothly be formed by,for example, a blade surface of the hook-shaped treating portion 68. Onthe other hand, the shaver shaves the surface by the rotation of thehead, and hence it is more difficult to smoothen the cut-off surfacethan in the case where the ultrasonic treatment device 32 is used.

It is to be noted that when an abrader burr is used in the treatment ofa soft tissue such as the meniscus 142 or 144, the treated surface (anabraded surface) is disadvantageously made fluffy as shown in FIG. 9B.Consequently, in the case where the abrader burr is used, it is moredifficult to smoothen the surface and it is easier to generate concaveand convex areas in the excised region than in the case where theultrasonic treatment device 32 is used. As shown in FIG. 9A and FIG. 9B,in the case where the treating portion 68 of the ultrasonic treatmentdevice 32 is used, the treated surface is more easily formed preciselyand smoothly than in the case where the abrader burr is used. Therefore,in the case where the ultrasonic treatment device 32 is used, theconcave and convex areas of the excised region can be decreased ascompared with the case where the abrader burr is used.

Thus, the ultrasonic treatment device 32 is used, and hence the devicecan smoothly be moved between the treatment region of the meniscus 142or 144 and the femur 112 and between the treatment region of themeniscus 142 or 144 and the tibia 114. Therefore, the treatment in whichthe ultrasonic treatment device 32 is used contributes to a smooth jointmovement in which sticking of the femur 112 to the meniscus 142 or 144that remains to be excised and sticking of the tibia 114 to the meniscus142 or 144 that remains to be excised are eliminated.

As described above, the surgeon performs the treatment of the damagedregion of the meniscus 142 or 144 to the patient. Afterward, the surgeonpulls out the treating portion 68 of the ultrasonic treatment device 32from the second cannula 18 b and pulls out the distal end of thearthroscope 22 from the first cannula 18 a. Furthermore, the first andsecond cannulas 18 a and 18 b are removed from the knee joint 100.Further, the portals 102 and 104 are sutured.

As described above, the technique of excising the damaged region of themeniscus 142 or 144 under the arthroscope 22 can be considered asfollows.

By use of the treatment system 10, the surgeon can perform a series oftreatment of excising the synovial membrane 134 and excising the damagedregion of the meniscus 142 or 144 with the treating portion 68 of theultrasonic treatment device 32 while the one ultrasonic treatment device32 is disposed as it is in the second cannula 18 b. Consequently, duringthe surgical treatment, the surgeon does not need to replace thetreatment device 32 disposed in the joint cavity 136, and hence surgicaltreatment time can be shortened.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, a movablerange to the second cannula 18 b can be increased, and treatment regionssuch as the anterior horn of the medial meniscus 142 and the posteriorhorns and posterior nodes of the medial meniscus 142 and the lateralmeniscus 144 can more easily be approached as compared with the casewhere the shaver is used. Additionally, in the treatment of theultrasonic treatment device 32, the more precise and smoother treatedsurface can be formed than in the case where the shaver or the abraderburr is used. Consequently, for example, when the surgeon performs thetreatment by use of the ultrasonic treatment device 32 and then thepatient bends and stretches the knee joint 100 to move the meniscus 142or 144, the meniscus can be prevented from being stuck on the femur 112or the tibia 114, which can contribute to the smooth joint movement.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use a high frequency device (an RF device). Asshown in FIG. 9C, when the treatment is performed by using the highfrequency device, there is the fear that the surface (an inferior boneof the cartilage) is invaded by heat. On the other hand, as shown inFIG. 9A, in the case where the ultrasonic treatment device 32 is used,for example, the cartilage 114 a of the tibia 114 under the meniscus 142or 144 is less invaded by heat, and thermal necrosis is prevented frombeing caused to the cartilage 114 a in the treated surface excised bythe treating portion 68, as compared with the case where the highfrequency device is used.

Next, there will be described a method in which the surgeon uses thetreatment system 10 mentioned above to perform a surgical treatment ofexcising a damaged region of the cartilage 112 a under the arthroscope22 to the patient who has the damaged region in the spherical cartilage112 a. Here, together with the removal of the synovial membrane 134 andthe treatment of the damaged region of the meniscus 142 or 144, there isdescribed a method of removing a denatured cartilage in a case whereosteochondritis dissecans (OCD) occur.

The knee joint 100 might cause the osteochondritis dissecans. Thesurgeon confirms the osteochondritis dissecans by use of MRI or thelike. Degrees of progress of the osteochondritis dissecans are indicatedas, for example, grades of ICRS (International Cartilage RepairSociety), i.e., Grade 0 (Normal), Grade 1 (Stable, continuity: Softenedarea covered by intact cartilage), Grade 2 (Partial discontinuity,stable on probing), Grade 3 (Complete discontinuity, “dead in situ”, notdislocated), Grade 4 (Dislocated fragment, loose within the bed or emptydefect. >10 mm in depth is B-subgroup). In the knee joint 100, thecartilages 112 a are damaged in, for example, the medial condyle 122 andthe lateral condyle 124 of the femur 112 due to the osteochondritisdissecans.

There are prepared the instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofexcising the cartilage and the bone. It is to be noted that the treatingportion 68 of the ultrasonic treatment device 32 is formed into thesuitable shape, e.g., the hook type.

The surgeon disposes the distal end of the arthroscope 22 in the jointcavity 136 of the knee joint 100 of the patient through the firstcannula 18 a. The surgeon fills the joint cavity 136 of the knee joint100 of the patient with the saline (the perfusion liquid) by use of theperfusion device 16. In this state, the surgeon suitably observes theinside of the joint cavity 136 of the knee joint 100 of the right kneeby use of the arthroscope 22. Further, the surgeon disposes the damagedregion of the meniscus 142 or 144 in the view field of the arthroscope22 to confirm the damage. Additionally, the surgeon confirms theinflammation of the synovial membrane 134 in the joint capsule 130 ofthe knee joint 100.

The surgeon disposes the treating portion 68 of the ultrasonic treatmentdevice 32 in the joint cavity 136 of the knee joint 100 of the patientthrough the second cannula 18 b. In a case where a region that causesinflammation is present in the synovial membrane 134 of the jointcapsule 130 confirmed with the arthroscope 22, the surgeon excises theinflamed region from the synovial membrane 134 with the treating portion68 of the ultrasonic treatment device 32 to which the ultrasonicvibration is transmitted, while observing the inflamed region with thearthroscope 22. Similarly, the ultrasonic vibration is transmitted tothe same treating portion 68 of the ultrasonic treatment device 32 toexcise the damaged region of the meniscus 142 or 144. That is, whennecessary, the inflamed region of the synovial membrane 134 or thedamaged region of the meniscus 142 or 144 is excised as described above,or when possible, the damaged region of the meniscus 142 or 144 issutured and treated.

For example, when the cartilage 112 a attached to the medial condyle 122of the femur 112 is damaged, the surgeon confirms the grade of theosteochondritis dissecans with the arthroscope 22. By use of thearthroscope 22, the surgeon confirms whether a part of the cartilage 112a is softened (Grade 1), whether laceration such as partial tear ispresent in a part of the cartilage 112 a (Grade 2), whether a part ofthe cartilage 112 a is discontinued from a bone (the medial condyle 122of the femur 112) to which the cartilage 112 a adheres (Grade 3), orwhether a bone cartilage piece is liberated and the bone (the medialcondyle 122 of the femur 112) to be hidden behind the cartilage 112 a isexposed (Grade 4), to judge the grade. Additionally, in each of Grades 1to 4, presence/absence of the bone spurs and presence/absence ofhardened regions are confirmed to the medial condyle 122 and the lateralcondyle 124 of the femur 112.

Further, as shown in FIG. 10A, the treating portion 68 of the ultrasonictreatment device 32 is brought into contact with the treatment objectregion of the cartilage 112 a while observing the treatment objectregion always disposed in the view field of the arthroscope 22. In thisstate, the switch 36 is operated to suitably perform the treatment tothe treatment object region by use of the ultrasonic vibration. At thistime, as shown in FIG. 10B, the surgeon can easily form the treatedsurface by the treating portion 68 to which the ultrasonic vibration ofthe ultrasonic treatment device 32 is transmitted, as the smooth surfacewithout forming any corner portions therein, by suitably moving thetreating portion 68 in accordance with the movement of the probe 66 inthe axial direction. As shown in FIG. 10B, when the treatment objectregion of the cartilage 112 a is removed, a dented region having asubstantially circular vertical cross section is formed, and there aresmoothly continued the removed surface from which the treatment objectregion of the cartilage 112 a is removed and the non-removed surfaceadjacent to the removed surface. In consequence, the region treated withthe treating portion 68 of the ultrasonic treatment device 32 by thesurgeon is hard to be stuck on another region.

Here, as shown in FIG. 10B, the treatment is performed without leavingany corner portions in treated regions of the cartilage 112 a when thesurgeon judges as one of Grade 2 to Grade 4, as well as the softenedregion 112 b of the cartilage 112 a is removed.

When the surgeon judges that a condition of a part of the cartilage 112a is Grade 2, as shown in FIG. 10A, the treating portion 68 of theultrasonic treatment device 32 is faced to a torn region (a treatmentobject region) 112 b of the cartilage 112 a. Further, the torn region ofthe cartilage 112 a is removed by moving the treating portion 68 alongthe axial direction of the probe 66 while transmitting the ultrasonicvibration to the treating portion 68 of the ultrasonic treatment device32. In addition, the bone spur formed in Grade 2 is removed bytransmitting the ultrasonic vibration to the treating portion 68 of theultrasonic treatment device 32. Also at this time, the treatment isperformed without leaving any corner portions in treated regions of thecartilage 112 a and the medial condyle 122 of the femur 112.

When the surgeon judges that the condition of a part of the cartilage112 a is Grade 3, as shown in FIG. 10A, the treating portion 68 of theultrasonic treatment device 32 is faced to the torn region (thetreatment object region) 112 b of the cartilage 112 a and a torn regionof the medial condyle 122 of the femur 112. Further, the torn region 112b of the cartilage 112 a and the torn region of the medial condyle 122of the femur 112 are removed together with the osteophyte formed in themedial condyle 122 of the femur 112 and the like, by moving the treatingportion 68 along the axial direction of the probe 66 while transmittingthe ultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32. Also at this time, the treatment is performedwithout leaving any corner portions in the treated regions of thecartilage 112 a and the medial condyle 122 of the femur 112.

When the surgeon judges that the condition of a part of the cartilage112 a is Grade 4, the torn region (the treatment object region) 112 b ofthe cartilage 112 a shown in FIG. 10A might peel from the medial condyle122 of the femur 112. In this case, when the inferior bone (the medialcondyle 122 of the femur 112) of the cartilage 112 a undergoes necrosisdue to an interruption in circulation of blood or the like, the bonecartilage piece separates to be liberated as a loose body in the jointcapsule 130. In addition, the loose body might be separated also fromthe cartilage 112 a into the joint capsule 130. In such a case, thetreating portion 68 of the ultrasonic treatment device 32 is faced tothe torn region 112 b of the cartilage 112 a and the torn region of themedial condyle 122 of the femur 112. Further, the torn region 112 b ofthe cartilage 112 a and the torn region of the medial condyle 122 of thefemur 112 are removed together with the bone spur formed in the medialcondyle 122 of the femur 112, by moving the treating portion 68 alongthe axial direction of the probe 66 while transmitting the ultrasonicvibration to the treating portion 68 of the ultrasonic treatment device32. Also at this time, the treatment is performed without leaving anycorner portions in the treated regions of the cartilage 112 a and themedial condyle 122 of the femur 112. It is to be noted that the regionliberated from the cartilage 112 a is sucked or curetted to be removed.Further, excision of the deformed cartilage 112 a, removal of thecuretted or liberated cartilage piece, and grafting of the cartilage 112a are carried out. For example, when the bone cartilage piece isgrafted, a region to be grafted needs to be dissected. In this case, theultrasonic vibration is transmitted to the treating portion 68 of theultrasonic treatment device 32 to smoothly continue the removed surfaceand the non-removed surface adjacent to the removed surface as shown inFIG. 10B, thereby carrying out the dissection. Further, the bonecartilage piece is fixed by a known method.

Thus, in accordance with the condition, the treating portion 68 is movedalong the axial direction of the probe 66 while transmitting theultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32, to suitably dissect the cartilage 112 a. Inaddition, the ultrasonic vibration is transmitted to the treatingportion 68 of the same ultrasonic treatment device 32, to remove thebone spur. Also when the bone spur is removed, the treatment isperformed without leaving any corner portions and the smooth surface isformed without forming any corner portions in the same manner as shownin FIG. 10B.

Here, there has been described the example where the cartilage 112 a ofthe femur 112 and the femur 112 are treated, but the inferior cartilage118 a (see FIG. 4) of the patella 118 in chondromalacia patellae cansimilarly be treated.

As described above, the technique of removing the damaged region 112 bof the cartilage 112 a under the arthroscope 22 can be considered asfollows.

By use of the treatment system 10, the surgeon can perform a series oftreatment of removing the cartilage 112 a and the treatment objectregion of the femur 112 with the treating portion 68 of the treatmentdevice 32 while the one ultrasonic treatment device 32 is disposed as itis in the second cannula 18 b. Consequently, by use of the treatmentsystem 10, the surgeon can perform a series of treatment of excising thesynovial membrane 134, excising the damaged region of the meniscus 142or 144 and removing the cartilage 112 a and the treatment object regionof the femur 112 with the treating portion 68 of the treatment device 32while the one ultrasonic treatment device 32 is disposed as it is in thesecond cannula 18 b.

Further, the surgeon has heretofore replaced and used differentinstruments to the portal 104 by, for example, using the shaver or thelike in a smoothening treatment of the cartilage 112 a and using theabrader burr or the like in the smoothening treatment of the femur 112,the tibia 114 or the patella 118. When the cartilage 112 a and thetreatment object region 112 b of the femur 112 are removed, theultrasonic treatment device 32 does not have to be replaced to theportal 104. These treatments can be performed with the one ultrasonictreatment device 32. Consequently, during the surgical treatment, thesurgeon does not have to replace the treatment device 32 disposed in thejoint cavity 136, and hence the surgical treatment time can beshortened.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range to the cannula 18 b can be increased, and treatmentregions such as back surfaces or the like of the medial condyle 122 andthe lateral condyle 124 of the femur 112 and a treatment region of ajoint surface (an inferior surface) of the patella 118 can more easilybe approached as compared with the case where the shaver or the abraderburr is used. Additionally, in the treatment of the ultrasonic treatmentdevice 32, the more precise and smoother treated surface can be formedthan in the case where the shaver or the abrader burr is used.Consequently, for example, when the surgeon performs the treatment byuse of the ultrasonic treatment device 32 and then the patient bends andstretches the knee joint 100 to move the femur 112, the tibia 114 andthe patella 118, the femur 112, the tibia 114 and the patella 118 can beprevented from being stuck on one another, which can contribute to thesmooth joint movement.

The abrader burr abrades the bone (the bone spur) that is the hardtissue by the periaxial rotation, and hence loads that act on theabrader burr increase in a case where the bone is abraded. Consequently,the abrader burr might noticeably entirely be vibrated by the loads ontothe treating portion. On the other hand, the treating portion 68 of theultrasonic treatment device 32 is not periaxially rotated but the bonecan be resected only by moving (vibrating) the treating portion in theaxial direction of the probe 66. Consequently, loads that act on thehousing 62 or the like through the treating portion 68 are small in acase where the bone is resected by the treating portion 68. Inconsequence, the ultrasonic treatment device 32 inserted into the jointcavity 136 of the knee joint 100 through the portal 104 does notnoticeably vibrate. That is, in the case where the bone is resected bythe treating portion 68, leaping of the treating portion 68 is notcaused by a rotary motion as in the abrader burr, and hence damages ofthe peripheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use the high frequency device. When the treatmentis performed by using the high frequency device, there is the fear thatthe surface is invaded by heat. On the other hand, when the ultrasonictreatment device 32 is used, normal regions of the cartilages 112 a, 114a and 118 a of the femur 112, the tibia 114 and the patella 118 are lessinvaded by heat, and the thermal necrosis is prevented from being causedto the cartilages 112 a, 114 a and 118 a.

Next, there will be described a method in which the surgeon uses thetreatment system 10 mentioned above to excise the anterior cruciateligament 152 under the arthroscope 22 to the patient who has the damagedregion in the anterior cruciate ligament 152, and a reconstructingmethod of the anterior cruciate ligament 152. Additionally, here, thereare treated the inflammation of the synovial membrane 134, the damagedregion of the meniscus 142 or 144 and the osteochondritis dissecans(OCD) which often occur together with the damage of the anteriorcruciate ligament 152.

There are prepared an instrument to form the portals 102 and 104 in theknee joint 100, and an instrument for use in a surgical treatment ofreconstructing the anterior cruciate ligament 152. It is to be notedthat the treating portion 68 of the ultrasonic treatment device 32 isformed into a suitable shape such as the hook type.

When the anterior cruciate ligament 152 is reconstructed, the surgeonfirst collects a tendon to be implanted from a hamstring (asemitendinosus muscle, or a gracilis muscle), a patellar tendon or thelike and prepares a graft 156 (see FIG. 14) that replaces the anteriorcruciate ligament 152. The surgeon judges a position of the patient fromwhich the tendon to be implanted is to be collected to prepare the graft156, depending on, for example, a patient's condition, an activity planfrom now on, or the like. Various ways to consider selection of thetendon to be implanted are present, but are known, and hencedescriptions thereof are omitted here.

The surgeon disposes the distal end of the arthroscope 22 in the jointcavity 136 of the knee joint 100 of the patient through the firstcannula 18 a. The surgeon uses the perfusion device 16 to fill the jointcavity 136 of the knee joint 100 of the patient with the saline whilesucking the inside of the joint cavity. In this state, the surgeonsuitably observes the inside of the joint cavity 136 of the knee joint100 by use of the arthroscope 22.

The surgeon disposes the treating portion 68 of the ultrasonic treatmentdevice 32 in the joint cavity 136 of the knee joint 100 of the patientthrough the second cannula 18 b. As required, the surgeon excises theinflamed region of the synovial membrane 134 and the damaged region ofthe meniscus 142 or 144 as described above. In addition, the surgeonappropriately treats regions to which the osteochondritis dissecans arecaused in the femur 112, the tibia 114 and the patella 118.

The arthroscope 22 passed through the first cannula 18 a is moved to theposterior side of the knee joint 100, to confirm a remaining region ofthe anterior cruciate ligament 152 to the cartilage 112 a of the lateralcondyle 124 of the femur 112. As shown in FIG. 11A, the surgeon confirmsa footprint region (an anatomical position to which the anteriorcruciate ligament 152 adheres) 162 of the anterior cruciate ligament 152on a femur 112 side with the arthroscope 22, and also confirms a ridge(bone ridge) 162 a (see FIG. 11B) of the start region of the anteriorcruciate ligament 152. Further, the treatment of the remaining region ofthe anterior cruciate ligament 152 to the cartilage 112 a on the femur112 side is performed with the ultrasonic treatment device 32. That is,as shown in FIG. 11A, the ridge 162 a of the start region of theanterior cruciate ligament 152 is dissected in a state shown in FIG.11B, by moving the treating portion 68 along the axial direction of theprobe 66 while transmitting the ultrasonic vibration to the treatingportion 68 of the ultrasonic treatment device 32. Specifically, as shownin FIG. 11A, the treating portion 68 of the ultrasonic treatment device32 is disposed to abut on the remaining region of the anterior cruciateligament 152, and the treating portion 68 is moved along the axialdirection of the probe 66 while transmitting the ultrasonic vibration tothe treating portion 68 of the ultrasonic treatment device 32, therebyresecting the remaining region. At this time, the treating portion 68 ofthe ultrasonic treatment device 32 can simultaneously cut off a softtissue of the remaining region of the anterior cruciate ligament 152 andthe hard tissue of the femur 112. In consequence, the ultrasonictreatment device 32 does not have to be replaced to the second cannula18 b.

As shown in FIG. 11B, a position of the footprint region 162 at whichthe start region of the removed anterior cruciate ligament 152 has beenpresent is confirmed with the arthroscope 22 again. This position of thefootprint region 162 is to be a position of one end of a tunnel 166 onthe femur 112 side. To clarify the position of the one end of the tunnel166, a part of the footprint region 162 of the anterior cruciateligament 152 of the femur 112 is resected with the treating portion 68of the ultrasonic treatment device 32 to which the ultrasonic vibrationis transmitted, to form a concave hole 164 of a suitable depth shown inFIG. 11C. The surgeon uses the concave hole 164 as an auxiliary hole (aguiding hole) to form the tunnel 166 at a desirable position by anafter-mentioned drill. In addition, the surgeon uses the concave hole164 as a marking. The concave hole 164 is formed from a region to whichthe ligament 152 has adhered (the footprint region) toward a lateralsurface of the lateral condyle 124 of the femur 112.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range to the cannula 18 b can be increased, and a treatmentregion such as the footprint region 162 in which the start region of theanterior cruciate ligament 152 of the femur 112 has been present canmore easily be approached as compared with the case where the shaver orthe abrader burr is used. Additionally, the treating portion 68 of theultrasonic treatment device 32 can simultaneously resect a remainingligament and the femur 112. Consequently, when the surgeon performs thetreatment by use of the ultrasonic treatment device 32 according to thisembodiment, inserting and removing of the treatment device through thesecond cannula 18 b, e.g., replacing of the shaver to remove the softtissue with the abrader burr to remove the hard tissue can beeliminated.

Afterward, as shown in FIG. 12A, the surgeon moves the arthroscope 22passed through the first cannula 18 a to an anterior side of the kneejoint 100, to confirm the remaining region of the anterior cruciateligament 152 to the cartilage 114 a on a tibia 114 side in the samemanner as in the femur 112 side. As shown in FIG. 12A, the surgeonconfirms a footprint region (an anatomical position to which theanterior cruciate ligament 152 adheres) 172 of the anterior cruciateligament 152 on the tibia 114 side with the arthroscope 22. Further, atreatment of the remaining region of the anterior cruciate ligament 152to the cartilage 114 a on the tibia 114 side is performed with theultrasonic treatment device 32. That is, as shown in FIG. 12A, the endregion of the anterior cruciate ligament 152 is dissected in a stateshown in FIG. 12B, by moving the treating portion 68 along the axialdirection of the probe 66 while transmitting the ultrasonic vibration tothe treating portion 68 of the ultrasonic treatment device 32.Specifically, as shown in FIG. 12A, the treating portion 68 of theultrasonic treatment device 32 is disposed to abut on the remainingregion of the anterior cruciate ligament 152, and the treating portion68 is moved along the axial direction of the probe 66 while transmittingthe ultrasonic vibration to the treating portion 68 of the ultrasonictreatment device 32, thereby resecting the remaining region. At thistime, the treating portion 68 of the ultrasonic treatment device 32 cansimultaneously cut off the soft tissue of the remaining region of theanterior cruciate ligament 152 and the hard tissue of the tibia 114. Inconsequence, the ultrasonic treatment device 32 does not have to bereplaced to the second cannula 18 b.

As shown in FIG. 12B, a position of the footprint region 172 at whichthe end region of the removed anterior cruciate ligament 152 has beenpresent is confirmed with the arthroscope 22 again. This position of thefootprint region 172 is to be a position of one end of a tunnel 176 onthe tibia 114 side. To clarify the position of the one end of the tunnel176, the footprint region 172 of the anterior cruciate ligament 152 ofthe tibia 114 is resected with the treating portion 68 of the ultrasonictreatment device 32 to which the ultrasonic vibration is transmitted, toform a concave hole 174 of a suitable depth shown in FIG. 12C. Thesurgeon uses the concave hole 174 as an auxiliary hole (a guiding hole)to form the tunnel 176 at a desirable position by the after-mentioneddrill. In addition, the surgeon uses the concave hole 174 as a marking.The concave hole 174 is formed from the region to which the ligament 152has adhered (the footprint region) toward a medial surface of a roughsurface of the tibia 114.

The ultrasonic treatment device 32 is removed from the second cannula 18b after these treatments are ended.

Afterward, as shown in FIG. 13A, the surgeon forms a small hole in thetibia 114 by use of, for example, a wire-shaped first drill, andenlarges a diameter of the hole by a second drill having a largerdiameter in accordance with a cross section of the graft 156 to form thetunnel 176 in the tibia 114. Similarly, as shown in FIG. 13B, the tunnel166 is formed in the femur 112.

Here, for the purpose of forming the tunnel 166, an instrument 72 thatguides the drill (not shown) is used. The instrument 72 has a main body74 and a guiding tube 76 that guides the drill toward one end 74 a ofthe main body 74.

The surgeon forms the concave hole 164 at one end of a position to formthe bone tunnel 166 in the femur 112 with the treating portion 68 of theultrasonic treatment device 32. Consequently, for example, the one end74 a of the main body 74 of the instrument 72 that guides the drill toform the bone tunnel 166 is fixed to the concave hole 164 through theportal 104 from which the second cannula 18 b is pulled out, immediatelybefore the bone tunnel 166 is formed.

The guiding tube 76 of the instrument 72 is supported at the other end74 b of the main body 74. At this time, in the main body 74, a distalend 76 a of the guiding tube 76 is directed toward the one end 74 a ofthe main body 74. That is, the distal end 76 a of the guiding tube 76 isdisposed toward the concave hole 164. Further, the surgeon passes theguiding tube 76 supported at the other end 74 b of the main body 74, ina direction from the lateral side of skin of the right knee toward theone end 74 a of the main body 74. The distal end 76 a of the guidingtube 76 is disposed to abut on a lateral side of the lateral condyle 124of the femur 112. It is to be noted that, when the concave hole 164 isused as a supporting point, the distal end 76 a of the guiding tube 76is passed from a suitable position of the lateral side of the skin ofthe right knee, to be supported at a suitable position of the lateralside of the lateral condyle 124 of the femur 112. Further, the unshowndrill is guided from a proximal end 76 b of the guiding tube 76 towardthe distal end 76 a of the guiding tube 76. The bone tunnel 166 isformed by the drill toward the one end 74 a of the main body 74 from astate where the distal end of the drill is disposed to abut on the outerside of the lateral condyle 124 of the femur 112. In consequence, thebone tunnel 166 is formed from the outer side of the skin toward theconcave hole 164. At this time, the one end 74 a of the main body 74 ofthe instrument 72 is applied to the concave hole 164 of the femur 112,and hence one end of the bone tunnel 166 is easily formed at ananatomically correct position to the femur 112. That is, the concavehole 164 of the femur 112 is used as the supporting point to form thebone tunnel (tunnel) 166 between the concave hole 164 of the femur 112and the outer surface of the lateral condyle 124 of the femur 112.Afterward, the second drill having a larger diameter than the firstdrill is moved along the first drill to suitably enlarge the tunnel 166in accordance with an outer diameter of the graft 156.

Here, for the purpose of forming the bone tunnel 176, an instrument 82that guides the drill (not shown) is used. The instrument 82 has a mainbody 84 and a guiding tube 86 that guides the drill toward one end 84 aof the main body 84.

In addition, the surgeon forms the concave hole 174 at one end of aposition to form the bone tunnel 176 in the tibia 114 with the treatingportion 68 of the ultrasonic treatment device 32. Consequently, forexample, the one end 84 a of the main body 84 of the instrument 82 thatguides the drill to form the tunnel 176 is fixed to the concave hole 174through the portal 104 from which the second cannula 18 b is pulled out,immediately before the bone tunnel 176 is formed.

The guiding tube 86 of the instrument 82 is supported at the other end84 b of the main body 84. At this time, in the main body 84, a distalend 86 a of the guiding tube 86 is directed toward the one end 84 a ofthe main body 84. That is, the distal end 86 a of the guiding tube 86 isdisposed toward the concave hole 174. Further, the surgeon passes theguiding tube 86 supported at the other end 84 b of the main body 84, ina direction from the lateral side of the skin of the right knee towardthe one end 84 a of the main body 84. The distal end 86 a of the guidingtube 86 is disposed to abut on a rough surface of a front surface of thetibia 114. It is to be noted that, when the concave hole 174 is used asthe supporting point, the distal end 86 a of the guiding tube 86 ispassed from a suitable position of the lateral side of the skin of theright knee, to be supported at a suitable position of the outer side ofthe rough surface of the tibia 114. Further, the unshown drill is guidedfrom a proximal end 86 b of the guiding tube 86 toward the distal end 86a of the guiding tube 86. The bone tunnel 176 is formed by the drilltoward the one end 84 a of the main body 84 from a state where thedistal end of the drill is disposed to abut on the lateral side of therough surface of the tibia 114. In consequence, the bone tunnel 176 isformed from the lateral side of the skin toward the concave hole 174. Atthis time, the one end 84 a of the main body 84 of the instrument 82 isapplied to the concave hole 174 of the tibia 114, and hence one end ofthe bone tunnel 176 is easily formed at an anatomically correct positionto the tibia 114. That is, the concave hole 174 of the tibia 114 is usedas the supporting point to form the bone tunnel 176 between the concavehole 174 of the tibia 114 and the rough surface of the tibia 114.Afterward, the second drill having a larger diameter than the firstdrill is moved along the first drill, to suitably enlarge the bonetunnel 176 in accordance with the outer diameter of the graft 156.

For example, when a position to which an end of the anterior cruciateligament 152 has adhered is dissected by using the abrader burr, it hasbeen difficult to form the concave hole due to the problem ofaccessibility or the problem that treatment time is lengthened. Here,the concave holes 164 and 174 are suitably formed by using theultrasonic treatment device 32, and hence the one end of each of theknown instruments 72 and 82 that guide the first drill to form the bonetunnels 166 and 176 can exactly be positioned. Consequently, the bonetunnels 166 and 176 can exactly be prepared more easily than before, ina state where the instrument is matched with each of the ends (the startregion and the end region) of the anterior cruciate ligament 152 beforedamaged, to the femur 112 and the tibia 114.

The instruments 72 and 82 and the like are removed, and then, as shownin FIG. 14, the graft 156 prepared in advance is inserted through thebone tunnels 166 and 176 into the joint cavity 136 of the knee joint100, to fix the one end of the graft 156 to the lateral side of thelateral condyle 124 of the femur 112 and to fix the other end of thegraft to the rough surface of the tibia 114. At this time, the graft 156may be inserted from the femur 112 side toward the tibia 114 side, ormay be inserted from the tibia 114 side toward the femur 112 side. Oneof the one end and the other end of the graft 156 is fixed with a fixingtool 92.

As described above, the technique of excising the damaged region of theanterior cruciate ligament 152 under the arthroscope 22 and thetechnique of reconstructing the anterior cruciate ligament 152 can beconsidered as follows.

By use of the treatment system 10, a series of treatment of removing thedamaged anterior cruciate ligament 152 and exposing the footprintregions 162 and 172 can be performed with the treating portion 68 of thetreatment device 32, while the one ultrasonic treatment device 32 isdisposed as it is in the second cannula 18 b. The surgeon has heretoforereplaced and used different instruments to the portal 104 by, forexample, using the shaver or the like in a removing treatment of theremaining ligament of the anterior cruciate ligament 152 and using theabrader burr or the like in the smoothening treatment (the exposingtreatment) of the footprint regions 162 and 172 of the hard tissue. Whenthe remaining ligament of the anterior cruciate ligament 152 and thetreatment object regions of the footprint regions 162 and 172 areremoved, the ultrasonic treatment device 32 does not have to be replacedto the portal 104. These treatments can be performed with the oneultrasonic treatment device 32. Consequently, during the surgicaltreatment, the surgeon does not have to replace the treatment device 32disposed in the joint cavity 136, and hence the surgical treatment timecan be shortened.

In addition, the footprint regions 162 and 172 are dissected, andsimultaneously, the concave holes 164 and 174 can be formed with thetreating portion 68 of the ultrasonic treatment device 32 withoutreplacing the tool. In consequence, the one end of each of theinstruments 72 and 82 to suitably form the bone tunnels 166 and 176 caneasily be positioned to the concave holes 164 and 174.

When the bone tunnels 166 and 176 are formed by utilizing the concaveholes 164 and 174 prepared by using an ultrasonic output under thearthroscope 22, shift of the one end of each of the instruments 72 and82 can be prevented, and hence the bone tunnels 166 and 176 can moreexactly be prepared at the correct positions. At this time, the concaveholes 164 and 174 are prepared and the concave holes 164 and 174 areutilized, and hence the bone tunnels 166 and 176 can be formed at thecorrect positions without necessarily using an X-ray.

The probe 66 of the ultrasonic treatment device 32 can be formed intothe suitable shape, and the treating portion 68 can be formed to besmaller than the shaver or the abrader burr. Consequently, in thetreatment in which the ultrasonic treatment device 32 is used, themovable range to the cannula 18 b can be increased, and a treatmentregion such as the rear side of the knee joint 100 can more easily beapproached as compared with the case where the shaver or the abraderburr is used. Additionally, in the treatment of the ultrasonic treatmentdevice 32, the more precise and smoother treated surface can be formedthan in the case where the shaver or the abrader burr is used.Consequently, when the surgeon performs the treatment by use of theultrasonic treatment device 32 and then the patient bends and stretchesthe knee joint 100 to move the femur 112, the tibia 114 and the patella118, the femur 112, the tibia 114 and the patella 118 can be preventedfrom being stuck on one another, which can contribute to the smoothjoint movement.

The abrader burr abrades the bone that is the hard tissue by theperiaxial rotation, and hence the loads that act on the abrader burrincrease in a case where the bone is abraded. Consequently, the abraderburr might noticeably entirely be vibrated by the loads onto thetreating portion. On the other hand, the treating portion 68 of theultrasonic treatment device 32 is not periaxially rotated but the bonecan be resected only by moving (vibrating) the treating portion in theaxial direction of the probe 66. Consequently, the loads that act on thehousing 62 or the like through the treating portion 68 are small in acase where the bone is resected by the treating portion 68. Inconsequence, the ultrasonic treatment device 32 inserted into the jointcavity 136 of the knee joint 100 through the portal 104 does notnoticeably vibrate. That is, in the case where the bone is resected bythe treating portion 68, the leaping of the treating portion 68 is notcaused by the rotary motion as in the abrader burr, and hence thedamages of the peripheral tissue can be decreased.

In addition, the surgeon uses the ultrasonic treatment device 32 andhence does not have to use the high frequency device. When the treatmentis performed by using the high frequency device, there is the fear thatthe surface is invaded by heat. On the other hand, when the ultrasonictreatment device 32 is used, the normal regions of the cartilages 112 aand 114 a of the femur 112 and the tibia 114 are less invaded by heat,and the thermal necrosis is prevented from being caused to thecartilages 112 a and 114 a.

It is to be noted that the concave holes 164 and 174 do not necessarilyhave to be formed. When the concave hole 164 is not formed, one end ofthe instrument 72 that guides the drill to form the bone tunnel 166 isdisposed in the footprint region 162 of the anterior cruciate ligament152 of the femur 112, to form the bone tunnel 166 in the femur 112. Thatis, the footprint region 162 is used as the supporting point in place ofthe concave hole 164, to form the bone tunnel 166 in the femur 112 byuse of the instrument 72. Similarly, when the concave hole 174 is notformed, one end of the instrument 82 that guides the drill to form thebone tunnel 176 is disposed in the footprint region 172 of the anteriorcruciate ligament 152 of the tibia 114, to form the bone tunnel 176 inthe tibia 114. That is, the footprint region 172 is used as thesupporting point in place of the concave hole 174, to form the bonetunnel 176 in the tibia 114 by use of the instrument 82.

Here, an order to prepare the bone tunnels 166 and 176 is described inorder of the femur 112 and the tibia 114, but, needless to say, theorder may be reversed, i.e., the order may be the tibia 114 and then thefemur 112.

In addition, here, there is described the example where the anteriorcruciate ligament 152 is reconstructed, but also when the posteriorcruciate ligament 154 is reconstructed, the treating portion 68 of theultrasonic treatment device 32 can similarly simultaneously cut off thesoft tissue of the remaining region of the posterior cruciate ligamentand the hard tissue of the femur 112. In consequence, the footprintregion of the posterior cruciate ligament 154 on the femur 112 side caneasily be confirmed by using the arthroscope 22. Similarly, the treatingportion 68 of the ultrasonic treatment device 32 can simultaneously cutoff the soft tissue of the remaining region of the posterior cruciateligament 154 and the hard tissue of the tibia 114. In consequence, thefootprint region of the posterior cruciate ligament 154 on the tibia 114side can easily be confirmed by using the arthroscope 22. In addition,the concave holes 164 and 174 can easily be formed under the arthroscope22 by moving the treating portion 68 along the axial direction of theprobe 66 while transmitting the ultrasonic vibration to the treatingportion 68 of the ultrasonic treatment device 32, to the footprintregions of the posterior cruciate ligaments 154 of the femur 112 and thetibia 114 in the same manner as in the footprint regions 162 and 172 ofthe anterior cruciate ligament 152.

Additional advantages and modifications will readily occur to thoseskilled in the art. Therefore, the invention in its broader aspects isnot limited to the specific details and representative embodiments shownand described herein. Accordingly, various modifications may be madewithout departing from the spirit or scope of the general inventiveconcept as defined by the appended claims and their equivalents.

What is claimed is:
 1. A surgical treatment of an anterior cruciateligament or a posterior cruciate ligament of a knee joint which is to beperformed under an arthroscope, the surgical treatment comprising:inserting the arthroscope and a treating portion of an ultrasonic deviceinto a knee joint cavity; bringing the treating portion of theultrasonic device into contact with a start region to which the anteriorcruciate ligament or the posterior cruciate ligament of a femur adheres,and excising the femur and a remaining ligament of the anterior cruciateligament, or the femur and a remaining ligament of the posteriorcruciate ligament by ultrasonically vibrating the treating portion,thereby exposing a footprint region of the femur; and bringing thetreating portion of the ultrasonic device into contact with an endregion to which the anterior cruciate ligament or the posterior cruciateligament of a tibia adheres, and excising the tibia and a remainingligament of the anterior cruciate ligament, or the tibia and a remainingligament of the posterior cruciate ligament by ultrasonically vibratingthe treating portion, thereby exposing a footprint region of the tibia.2. The surgical treatment according to claim 1, comprising forming atunnel between the footprint region of the tibia and a lateral side of arough surface of the tibia using the footprint region of the tibia as asupporting point.
 3. The surgical treatment according to claim 1,comprising forming a tunnel between the footprint region of the femurand a lateral surface of a lateral condyle of the femur using thefootprint region of the femur as a supporting point.